Building a Doctor Patient's Partnership

Jaime Correia de Sousa, MD, MPH Horizonte Family Health Unit

Matosinhos Health CentrePorto, Portugal

Sir Luke Fildes, Tate Gallery, London

Learning objectives

By the end of the session, participants should: Be aware of the different cultural patterns of access to

health care Understand why patients decide to seek help or advice Know the main reasons for consulting a doctor Be familiar with patient's explanations about health

and diseases Know the main consultation models used in family

practice Be able to build an effective Doctor Patient's

Partnership

Summary

Deciding to seek help or advice Deciding to see a doctor Cultural patterns of access to health care Reasons for consulting a doctor Patient's explanations about health and diseases Consultation length and consultation outcomes Building Doctor Patient's Partnership Consultation Models Some pitfalls in Patient-Physician Relationship

Deciding to see a doctor

Deciding to seek help or advice

Time

Tolerance threshold

Inte

nsity

Symptom SymptomSymptom

Cultural patterns of access to health care

The three sectors of health care

The popular sector

The folk sector

The professional sector

Kleinman (1980)

Reasons for consulting a doctor

1000 people

800 have symptoms

327 consider care

217 physician’s office

113 visit primary care

65 CAM provider

21 hospital outpatient clinic

14 home health

13 emergency department

8 hospitalized

<1 in an academic hospitalNew Ecology of Medical Care - 2000

In an average month:

Reasons for consulting (or not consulting) a doctor

Factors that influence the decision to consult The availability of medical care Whether the patient can afford it The failure or success of treatments within

the popular or folk sectors How the patient perceives the problem How others around him or her perceive the

problem

Reasons for encounter (RFE) – international studyRFE Code Frequency %

R05 Cough 38 4.1

A04 General weakness / tiredness 22 2.4

R21 Symptoms / complaints throat 20 2.2

A03 Fever 19 2.1

K31 Check blood pressure 18 2.2

K50 Medication CV system 17 1.9

L15 Knee symptoms / complaints 17 1.9

N01 Headache 15 1.6

R02 Shortness of breath 15 1.6

L14 Leg / thigh symptoms / complaints 14 1.5

Lamberts, Wood, Hoffmans-Okkes, 1993

Patient's explanations about health and diseases

The explanatory model

The explanatory model

Illness – the patient’s perspective

Disease – the doctor’s perspective

Questions to be answered

Patients’ expectations of consultationsDifferent phrasing is required to ask

questions about patients’ expectations; examples:

What are you concerned that it might be?’ What were you hoping we might be able to do

for this? What do you think might be the best plan of

action? How might I best help you with this? You’ve obviously given this some thought,

what were you thinking would be the best way of tackling this?

The purpose of the general practice consultation

The term is suggested to denote what patients have on their mind when waiting to see the doctor

Purposes of an actual consultation Several consultation purposes exist Wishes, what is perceived by the patient as

desirable The focus is directed towards the patient's wishes

prior to a consultation

Emphasis on the specific processes and outcomes.

Thorsen, Witt, Hollnagel, Malterud, 2001

Consultation length and consultation outcomes

Length of consultation with general practitioner

Country Mean (SD) time (minutes)

Germany 7.6 (4.3)

Spain 7.8 (4.0)

United Kingdom 9.4 (4.7)

Netherlands 10.2 (4.9)

Belgium 15.0 (7.2)

Switzerland 15.6 (8.7)

Overall 10.7 (6.7)

Deveugele, Derese, van den Brink Muinen, Bensing, De Maeseneer. BMJ. 2002 August 31; 325 (7362): 472

Consultation length in general practice

Patients are satisfied with care from general practice but often say that consultations are too short

Consultation length varies from country to country Important factors for consultation length are list size,

characteristics of doctors and patients, and character of the problem.

Characteristics of patients have as much effect on consultation length as the characteristics of countries and doctors combined

Consultation length in general practice Longer consultations are associated with a range of

better patient outcomes Modern consultations in general practice deal with

patients with more serious and chronic conditions. Increasing patient participation means more complex

interaction, which demands extra time. Difficulties with access and with loss of continuity lead

to further pressure on time. Longer consultations should be a professional priority,

with increased use of technology and more flexible practice management to maximise interpersonal continuity.

Freeman, Horder, Shah, Howie, 2002

Building Doctor Patient's Partnership

Building Doctor Patient's Partnership

Consultation Models

Pendleton - Doctor's Tasks

Levenstein - Patient-Centred Model

MacWhinney - Disease-Illness Model

Neighbour – The inner consultation

Pendleton’s Doctor's Tasks

Define the reason for the patient's attendance Consider other problems Together choose an appropriate action for each

problem Achieve a shared understanding of problems Involve the patient in the management of problems

and encourage acceptance of appropriate responsibility

Use time and resources appropriately Establish and maintain a relationship with the

patient which helps to achieve the other tasksPendleton (1984)

Patient-Centred Model

1. Exploring both the disease and the illness experience

2. Understanding the whole person 3. Finding common ground regarding

management4. Incorporating prevention and health

promotion5. Enhancing the Doctor-Patient relationship6. Being realistic

Levenstein (1984)

Patient-Centred Model

Building a Partnership

Building a Partnership Doctor patient partnerships in making decisions about

treatment can take different forms Three theoretical treatment decision making models

are the paternalistic, the shared, and the informed Most clinical consultations use elements of these

theoretical models, and these may change as the interaction unfolds

Doctors need to be aware of and be able to identify and explain the treatment options available

If doctor patient partnerships are to be promoted in clinical practice, current disincentives such as time and funding constraints will need to be restructured

Building a Partnership

Charles, Whelan, Gafni (1999)

Stages and competencies of involving patients in healthcare decisions

1. Implicit or explicit involvement of patients in decision-making process

2. Explore ideas, fears, and expectations of the problem and possible treatments

3. Portrayal of options

4. Identify preferred format and provide tailor made information

Stages and competencies of involving patients in healthcare decisions

5. Checking process: understanding of information and reactions—for example, ideas, fears, and expectations of possible options

6. Acceptance of process and preferred role in decision-making

7. Make, discuss, or defer decisions 8. Arrange follow up

Some pitfalls in Patient-Physician Relationship

Some pitfalls in Patient-Physician Relationship

Boundaries to the Patient-Physician Relationship

Gifts From Patients Patients we don’t like Dealing with Celebrity Patients and VIP’s Use of Chaperones During Physical

Exams